FY 2015 Inpatient PPS Proposed Rule Quality Provisions Webinar

FY 2015 Inpatient PPS Proposed Rule Quality Provisions Webinar June 2, 2014 AAMC Staff: Scott Wetzel, swetzel@aamc.org Mary Wheatley, mwheatley@aamc.org The AAMC has moved. New Address: 655 K Street, Washington DC

Agenda Summary of key quality and payment IPPS Provisions Value-based Purchasing (VBP) Hospital-Acquired Conditions (HAC) Hospital Readmissions Reduction Program (HRRP) Inpatient Quality Reporting (IQR) Measure by Measure Summary 2

Important Info on Proposed Rule In Federal Register on May available at http://www.gpo.gov/fdsys/pkg/fr-2014-05- 15/pdf/2014-10067.pdf Comments due June 30, 2014 AAMC Resources Posted: www.aamc.org/hospitalpaymentandquality May 27 webinar on Payment issues Jun 2 webinar on Quality issues 3

Quality Summary- FY 2015 5.5% at risk in FY 2015 for performance Hospital Compare IQR 25% reduction of market basket update for not reporting Measures must be publicly reported at least 1 year before proposing for VBP Readmission and HAC measures do not need to be publicly reported or included in IQR in advance, but they typically are VBP 1.5% of base DRG (goes up to 2% by FY2017) Readmissions 3.0% of base DRG HAC 1.0% of total payment 4 Rewards for good performance/penalties for poor performance Credit for improvement Readmission measures cannot be in VBP; HAC measures eligible for VBP Penalties for excess readmissions No credit for improvement Up to 3% of base DRG at risk Automatic penalty for one quarter of hospitals deemed as having worst performance. No credit for improvement HAC measures are in VBP too

Breakdown of Hospitals Affected By HAC Reduction Program 55 50 45 40 35 30 25 20 15 10 5 0 17.6 Percent of Hospitals Penalized by Type for FY 2015 26.6 17.6 Rural Large Urban Bed Size Under 100 41.7 Bed size Over 500 19 Non Teaching 52.7 Large Teaching Source: FY 2015 IPPS Proposed Rule Federal Register Pages 28366-28367 5 August 13, 2013

Multiple Data Sources Feed Into Measurement Claim measures CDC-NHSN Structural Measures HCAHPs EHR measures Chartabstracted measures Hospital Compare IQR How do the different sources affect data collection burden? How do differences in data source validity and reliability affect performance measurement? What are implications of e-measures, ICD-10 conversion on different data sources? VBP Readmissions HAC 6

FY 2015 IPPS Proposed Rule Key Takeaways (Quality Issues) Value Based Purchasing Program Proposal to remove several process of care measures in FY 2017 Corresponding proposed shift in domain weights for FY 2017 Feedback on ICD-10 transition Future episode of care measures Hospital Acquired Condition Reduction Program Starts FY 2015, disproportionately penalizes teaching hospitals 1% reduction affects Base DRGs, and add-on payments IME, DSH Feedback on feasibility of EHR all-cause harm measure Proposed increase in weighting for Domain 2 (CDC NHSN) to 75 percent starting FY 2016 Proposed single Surgical Site Infection (SSI) Standard Infection Ratio (SIR) calculation 7

FY 2015 IPPS Proposed Rule Key Takeaways (Quality Issues), continued Readmissions Reduction Program CABG proposed starting FY 2017 (also proposed for IQR in FY 2017) Update of planned readmission algorithm (Version 3.0) Inpatient Quality Reporting Program Single reporting of healthcare personnel influenza measure Expansion of CLABSI and CAUTI to non-icu locations starting CY 2015 previously finalized New episode of care, complication, and readmission measures proposed starting FY 2017 Voluntary electronic measure reporting 8

FY 2015 IPPS Proposed Rule Key Takeaways (Payment Issues) 1.3% hospital payment update (overall impact on all hospitals is 0.8%, but impact on major teaching hospitals is -1.3%) Documentation and Coding: -0.8% reduction for ATRA Recoupment (defers -0.55% prospective adjustment) Update labor market areas (based on most recent Census) Mostly technical GME changes Hospital Price Transparency: ACA requirement to make charges public 9

FY 2015 IPPS Proposed Rule Key Takeaways (Payment Issues) Continued 2 Midnight Rule: open for comments on how CMS should pay for short stays Medicare DSH: proposals related to the new labor market areas and the ACA DSH payment changes continue CMS will release separate interim final rule on ICD-10 with new compliance date (October 1, 2015) 10

Federal Register Pages Topic FR Pages (May 15, 2014) Value Based Purchasing Program 28117-28134 Hospital Acquired Conditions Program Hospital Readmissions Reduction Program Inpatient Quality Reporting Program 28134-28144 28105-28117 28218-28253 Payment Updates 28086-28088 Documentation & Coding 27995-27996 Wage Index & Occupational Mix Adjustment 28054-28070 GME Provisions 28144-28164 Medicare DSH ACA Changes 28094-28105 2 Midnight Rule and Short Stays 28169-28170 Outliers 28321-28324 11 New Technology 28028-28054

Agenda Summary of key quality and payment IPPS Provisions Value-based Purchasing (VBP) Hospital-Acquired Conditions (HAC) Hospital Readmissions Reduction Program (HRRP) Inpatient Quality Reporting (IQR) Measure by Measure Summary 12

Updates to VBP Program for FY 2015 Reduction in base DRGs increased from 1.25% to 1.5% to fund incentive pool Amount at risk is $1.4 billion First year of the efficiency domain (20% of the total VBP score). Domain contains one measure: Medicare Spending Per Beneficiary (MSPB) 13

Proposed Removal and Addition of Measures Six Topped Out Process of Care Measures Proposed for Removal (FY 2017) PN-6: Initial Antibiotic Selection for CAP in Immunocompetent Patient SCIP-Inf-2: Prophylactic Antibiotic Selection for Surgical Patients SCIP-Inf-3: Prophylactic Antibiotics Discontinued Within 24 Hours After Surgery End Time SCIP-INF-9: Postoperative Urinary Catheter Removal on Postoperative Day 1 or 2 SCIP-Card-2: Surgery Patients on a Beta Blocker Prior to Arrival That Received a Beta Blocker During the Perioperative Period SCIP-VTE-2: Surgery Patients Who Received Appropriate Venous Thromboembolism Prophylaxis Within 24 Hours Prior to Surgery to 24 Hours After Surgery Six Measures Proposed to be Added (FY 2017 & 2019) 2017 Hospital-onset Methicillin-Resistant Staphylococcus Aureas (MRSA) Bacteremia Clostridium Difficile (C.Diff) Infection Early Elective Deliveries (PC-01) Re-adoption of CLABSI (Current Measure, not the Reliability-adjusted Measure) 2019 Hospital-level Risk-standardized Complication Rate (RSCR) Following Elective Hip and Knee Arthroplasty Re-adoption of PSI-90 14 CMS removing several process of care measures and adding safety and outcome measures

Proposed VBP Domains for FY 2017 Previously Finalized Domain Weighting FY 2017 Proposed Domain Weighting FY 2017 25% 35% Clinical Care * Safety 25% 30% Clinical Care* Safety 25% 15% Efficiency HCAHPS 25% 20% Efficiency HCAHPS FY 2017 Proposal Process of Care measures (Clinical Care Domain) would be reduced 5% Safety Measure Domain would be increased 5% 15 * Clinical care includes process of care measures and other outcome measures (mortality)

16 Proposed Performance Periods FY 2017-2020

Possible Future Measure Topics Patient Experience Care Transition Measure (CTM-3) as part of the HCAHPS survey (In IQR--Scheduled to be reported on Hospital Compare in October 2014; Being considered for FY2018) Medical Episodes (Not in IQR) 30-day Episode: Kidney/urinary tract infection 30-day Episode: Cellulitis 30-day Episode: Gastrointestinal hemorrhage Surgical Episodes (Not in IQR) Surgical 30-day Episode: Hip replacement/revision Surgical 30-day Episode: Knee replacement/revision Surgical 30-day Episode: Lumbar spine fusion/refusion 17 Measures must be publicly reported for one year before being proposed for VBP

Impact of ICD-10 Background Transition to ICD-10 now scheduled to start October 1, 2015 Could result in disconnect between performance and benchmark periods impacting achievement and improvement scoring Feedback Requested CMS asking for feedback on how performance scoring should be adjusted under VBP. Possible options: o If measure performance results are substantially different, CMS could retrospectively adjust performance standards CMS could also perform similar adjustments to hospitals measure rates, scores, or TPSs. o CMS could only score measures on achievement CMS Analyzing Impact of ICD-10 Transition With the Following Actions: Assess impact on measure denominators after ICD-10 measure specifications are released Solicit feedback from maximum 9 hospitals to estimate impact of ICD-10 on their hospital VBP measure rates and denominator counts 18

VBP Discussion Suggestions or recommendations to address ICD-10 Have organizations tested performance measures with ICD-10? Any lessons learned from your organizations with ICD-10 testing? Implications for claims analyses Implications for historical benchmarking Feedback on measure changes for FY 2017 (slide 14) Concerns with transitioning away from the process of care measures? Concerns with new measures? 19

Agenda Summary of key quality and payment IPPS Provisions Value-based Purchasing (VBP) Hospital-Acquired Conditions (HAC) Hospital Readmissions Reduction Program (HRRP) Inpatient Quality Reporting (IQR) Measure by Measure Summary 20

HAC Reduction Program Recap HAC Reduction Program starting FY 2015 Hospitals in the worst performance quartile of HACs will face a 1 percent reduction in all payments (including IME and DSH) HAC reductions will be applied after adjustments for the VBP and the Readmission Reduction Programs CMS plans to report HAC Reduction Program data on Hospital Compare in December 2014 HAC Reduction Program has two domains: Domain 1 Claims measure Domain 2 CDC NHSN Measures Teaching hospitals disproportionately affected by HAC Program 21

HAC Reduction Program Framework Finalized for FY 2015 Total HAC Score Total HAC Score 25% of worst performing hospitals receive 1% reduction Domains Domain 1 (Weighted 35%) Domain 2 (Weighted 65%) Measures PSI-90 Composite Measure CLABSI and CAUTI Measures 22 August 13, 2013

HAC Reduction Program Framework Proposed for FY 2016 Total HAC Score Total HAC Score 25% of worst performing hospitals receive 1% reduction Domains Domain 1 (Weighted 25%) Domain 2 (Weighted 75%) Measures PSI-90 Composite Measure CLABSI, CAUTI, and SSI Measures 23 August 13, 2013

HAC Domains and Measures (Finalized) Domain 1 (AHRQ PSI-90 Composite) The PSI-90 Composite consists of: PSI-3: pressure Ulcer PSI-6: latrogenic pneumothorax PSI-7: central venous catheter-related blood stream infection rate. PSI-8: hip fracture rate PSI-12: postoperative PE/DVT rate PSI-13: sepsis rate PSI-14: wound dehiscence rate PSI-15: accidental puncture PSI-90 Composite could expand (currently under NQF review). Any changes to the measure would go through rulemaking before it is used in a reporting or performance program Domain 2 (CDC Measures) 2015 (2 measures) CAUTI CLABSI 2016 (1 additional measure) Surgical Site Infection (Colon Surgery and Abdominal Hysterectomy) 24 2017 (2 additional measures) MRSA C Diff

HAC Program: Additional Issues 30 day review and correction period before data is reported on Hospital Compare CMS requested feedback on inclusion of a extraordinary circumstance/disaster waiver exemption Data Collection Periods for FY 2015 & 2016 o FY 2015 Domain 1: July 2011 June 2013 Domain 2: CYs 2012 & 2013 o FY 2016 Domain 1: July 2012 June 2014 Domain 2: CYs 2013 & 2014 25

HAC Measure Scoring Methodology The performance range for each of the measures will be divided into 10 deciles. All hospitals will receive between 1 and 10 points for each measure CMS will handle ties by assigning all hospitals with the same result the same number of points based on the lowest appropriate percentile (i.e. if 13% of hospitals score a zero on a measure, all 13% would receive 1 point) CMS states that the worse quartile is defined by a score > 7 points. HPA analysis of the CMS file of hospital-specific scores shows that 23% of hospitals will be penalized CMS list of hospital level HAC information can be found here (table 17): http://www.cms.gov/medicare/medicare-fee-for-service- Payment/AcuteInpatientPPS/FY2015-IPPS-Proposed-Rule-Home-Page- Items/FY2015-IPPS-Proposed-Rule- Tables.html?DLPage=1&DLSort=0&DLSortDir=ascending To Calculate HAC Score (FY 2015): (Domain 1 Score x 35%) + (Domain 2 Score x 65%) =Total HAC Score* *Hospitals reporting measures in 2 domains 26

Surgical Site Infection (SSI) Scoring Methodology (FY 2016) CMS proposes to pool SSI for abdominal hysterectomies and colon procedures into a single standardized infection ratio (SIR) for each hospital 27

Potential Addition to HAC: Electronic All-Cause Harm Measure CMS is considering inclusion of an all-cause harm electronic measure CMS states some hospitals have already developed/adopted methodology to track and respond to all-cause harm through their EHR CMS requesting feedback on whether a standardized electronic composite measure should be used in conjunction, or instead of, PSI-90. o CMS seeking examples of an electronic allcause harm measures 28

HAC Discussion HAC Any questions/concerns with consolidating the two surgical site infections? Feedback on EHR all-cause harm measure Are there examples of this type of measure? Are there other ways to better measure HAC? Other questions/comments? 29

Agenda Summary of key quality and payment IPPS Provisions Value-based Purchasing (VBP) Hospital-Acquired Conditions (HAC) Hospital Readmissions Reduction Program (HRRP) Inpatient Quality Reporting (IQR) Measure by Measure Summary 30

Updates to Hospital Readmissions Reduction Program Maximum penalty increases to 3% in FY 2015 CMS proposes to add 1 new measure in FY 2017: CABG Proposed changes to Planned Readmissions Algorithm (Version 3.0) and to Total Hip/Total Knee Arthroplasty methodology Performance period July 1, 2010 through June 30, 2013 31

New Measure Proposed Starting FY 2017 Coronary Artery Bypass Graft (CABG) Recommended by MedPAC CABG also proposed for IQR starting FY 2017 Measures Currently in HRRP Program 30 day readmissions for: o HF (Started FY 2013) o AMI (Started FY 2013) o PN (Started FY 2013) o COPD (Starting FY 2015) o THA/TKA (Starting FY 2015) 32

Changes to Planned Readmissions Algorithm CMS proposes to apply a revised Planned Readmissions Algorithm (Version 3.0) to finalized measures starting FY 2015 and to CABG starting FY 2017. The Algorithm would no longer count the following procedures as planned readmissions: o Therapeutic Radiation (AHRQ CCS 211) o Cancer Chemotherapy (AHRQ CCS 224) when the principle diagnosis is not Maintenance Chemotherapy Additions to principal diagnoses that are always unplanned o Hypertension with complications (AHRQ CCS 99) o Acute pancreatitis (ICD-9 577.0) o Certain Biliary Tract Disease diagnoses 33

Refinement of THA/TKA 30-Day Readmission Cohort CMS is proposing to refine the measure methodology to exclude patients with hip fracture as the principal or secondary diagnosis. 34

HRRP Discussion Feedback on proposed change to planned readmission algorithm. Feedback on the THA/TKA readmissions measure changes AAMC will comment on the need to have CABG results published before including readmission rates in HRRP. Any other considerations related to measuring CABG readmissions? 35

Agenda Summary of key quality and payment IPPS Provisions Value-based Purchasing (VBP) Hospital-Acquired Conditions (HAC) Hospital Readmissions Reduction Program (HRRP) Inpatient Quality Reporting (IQR) Measure by Measure Summary 36

37 Overview of Measures in IQR

CMS Proposal to Removal IQR Measures Starting FY 2017 10 Measures Proposed for Removal from the IQR Program AMI-1: Aspirin at Arrival (Previously Suspended) AMI-3: ACEI or ARB for Left Ventricular Systolic Dysfunction- Acute Myocardial Infarction (AMI) Patients (NQF #0137) AMI-5: Beta-Blocker Prescribed at Discharge for AMI (NQF#0160) (Previously Suspended) HF-2: Evaluation of Left Ventricular Systolic Function (NQF #0135) SCIP-Inf-3: Prophylactic Antibiotics Discontinued Within 24 Hours After Surgery End Time (48 Hours for Cardiac Surgery) (NQF #0529) SCIP-Inf-4: Cardiac Surgery Patients with Controlled Postoperative Blood Glucose (NQF #03 SCIP-Inf-6: Surgery Patients with Appropriate Hair Removal (NQF #030) (Previously Suspended) SCIP-Card-2: Surgery Patients on Beta Blocker Therapy Prior to Arrival Who Received a Beta Blocker During the Perioperative Period (NQF #0284) SCIP-VTE-2: Surgery Patients Who Received Appropriate Venous Thromboembolism (VTE) Prophylaxis Within 24 Hours Prior to Surgery to 24 Hours After Surgery (NQF #0218) Participation in a Systematic Database for Cardiac Surgery (NQF #0113) 38

CMS Proposal to Remove/Retain IQR Measures Starting FY 2017 10 Measures Proposed to be Removed from IQR, but Retained as a Voluntary Electronic Clinical Quality Measure AMI-8a: Primary PCI Received Within 90 Minutes of Hospital Arrival (NQF #0163) PN-6: Initial Antibiotic Selection for Community-acquired Pneumonia (CAP) in Immunocompetent Patients (NQF #0147) SCIP-Inf-1: Prophylactic Antibiotic Received Within One Hour Prior to Surgical Incision (NQF #0527) SCIP-Inf-2: Prophylactic Antibiotic Selection for Surgical Patients (NQF #0528) SCIP-Inf-9: Urinary Catheter Removed on Postoperative Day 1 (POD1) or Postoperative Day 2 (POD2) With Day of Surgery Being Day Zero (NQF #0453) STK-2: Discharged on Antithrombotic Therapy (NQF #0435) STK-3: Anticoagulation Therapy for Atrial Fibrillation/flutter (NQF #0436) STK-5: Antithrombotic Therapy by the End of Hospital Day Two (NQF #0438) STK-10: Assessed for Rehabilitation (NQF #0441) VTE-4: Patients Receiving un-fractionated Heparin with Doses/labs Monitored by Protocol 39

CMS Proposal for New IQR Measures 5 Measures Proposed as IQR Required Measures Measure Hospital 30-day, all-cause, unplanned, risk-standardized readmission rate (RSRR) following coronary artery bypass graft (CABG) surgery Hospital 30-day, all-cause, risk-standardized mortality rate (RSMR) following coronary artery bypass graft (CABG) surgery Data Collection Claims Claims NQF- Endorsed? No No Hospital-level, risk-standardized 30-day episode-of-care payment measure for pneumonia Claims No Hospital-level, risk-standardized 30-day episode-of-care payment measure for heart failure Claims No Severe Sepsis and Septic Shock: Management Bundle (NQF# 500) Chart-abstracted Yes 6 Measures Proposed for Voluntary Electronic Health Reporting Hearing Screening Prior to Hospital Discharge (NQF #1354) PC-05 Exclusive Breast Milk Feeding and the subset 1042 measure PC-05a Exclusive Breast Milk Feeding Considering Mother s Choice (NQF #0480) CAC-3 Home Management Plan of Care (HMPC) Document Given to Patient/Caregiver Healthy Term Newborn (NQF #0716) AMI-2 Aspirin Prescribed at Discharge for AMI (NQF #0142) AMI-10 Statin Prescribed at Discharge (NQF #0639) 40

Breakdown of Finalized and Proposed IQR Measures for FY 2017 Chart Abstracted/ EHR 15 required measures Claims CDC NHSN HCAHPS Structural 21 measures 6 measures 1 measure 3 measures Required - Chart only (EHR specs not available) 3 measures Required - Chart or EHR 12 measures Voluntary - EHR only 16 measures 41 2014 CEHRT ecqm requires reporting of 16 measures of 29 (28 inpatient) across 3 domains

Proposals for Electronically Submitted Measures Starting FY 2017 Providers may voluntarily report 16 of 28 measures that align with EHR Incentive Program Must electronically report data for a full year EHR Incentive reporting period is modified to quarterly submission to match IQR See page 28245 of Fed Register Hospitals that successfully submit electronic measures would not need to submit chart abstracted data for validation purposes CMS had finalized a policy that electronic data would only be reported if it is accurate enough o o CMS now intends to publicly report this data (without being validated) when submitted for FY 2016 payment determination Data submitted for FY 2017 payment determination will also be publicly reported, but hospitals will have a preview period CMS intends to propose required electronic reporting for some IQR measures in next year s rule. 42

Additional Updates Expansion of CLABSI and CAUTI to select non-icu locations will start January 1, 2015 already finalized by CMS CMS proposes to update the planned readmission algorithm methodology and the THA/TKA measure Under the proposed rule, hospitals selected for data validation would submit 18 patient charts per quarter (for a total of 72 charts per year). The majority of these charts would be to validate HAI measures. For validation purposes, CMS would also allow digital images of the charts to be submitted through qualitynet. CMS clarifies that for the healthcare personnel vaccination measure (adopted for IQR and OQR), hospitals should only report a single vaccination count by CMS Certification Number (CCN). 43

IQR Discussion Are members submitting electronic measures? Have you noticed differences in performance? Do you prefer certain e-measures to chart-abstracted measures? (or vice versa?) AAMC has commented on validity issues and comparability of EHR and chart abstracted measures. Are there other concerns? Feedback on new required measures (slide 40) 44

Agenda Summary of key quality and payment IPPS Provisions Value-based Purchasing (VBP) Hospital-Acquired Conditions (HAC) Hospital Readmissions Reduction Program (HRRP) Inpatient Quality Reporting (IQR) Measure by Measure Summary 45

Individual Proposed Measure VBP Concerns with the proposed measures (CDC measures or elective delivery measure) Concerns with the future measures Care transition measure Medical and surgical episode of care measures Readmissions Concerns with the addition of (CABG) IQR Concerns with sepsis bundle measure Concerns with the claims measures Concerns with electronic measures 46

47 Thank You!

AAMC Staff Quality and Performance Programs Scott Wetzel, swetzel@aamc.org Mary Wheatley, mwheatley@aamc.org GME, DSH, Payment Issues Lori Mihalich-Levin, lmlevin@aamc.org Allison Cohen, acohen@aamc.org 48